10/21/2010 SOUTHERN CALIFORNIA (Alamitos Belmont) 10/26/2010 NORTHERN CALIFORNIA (Fairfield Post Acute Rehab) To Be Scheduled OTHER STATES via Webinar

10/21/2010SOUTHERN CALIFORNIA

(Alamitos Belmont)

10/26/2010NORTHERN CALIFORNIA (Fairfield Post Acute Rehab)

To Be ScheduledOTHER STATES via Webinar

MEDICAL RECORDS –A REFOCUS TO QUALITY RECORDS MANAGEMENT

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RHONDA ANDERSON, RHIAIN COORDINATION WITH

NORTH AMERICAN HEALTH CARE QUALITY SERVICES

Anderson Health Information Systems, Inc. 940 W. 17th St., Santa Ana, California 92706

Phone 714-558-3887Email: [email protected], [email protected],

[email protected]

PRESENTED BY

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PARTICIPANTS WILL o Identify the requirements as there is a refocus for

the Health Information/Records Department Management

o Identify the schedule for audits and related skill set

o Identify the areas of change and how to re-evaluate work tasks

o Identify training and other needsoReview the expectations for a well managed

HIM/Record Department

OBJECTIVES

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LIST 5-10 key items you think a well organized record dept. will have.

YOUR VISION

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KnowledgeSkills Utilized To Best Of AbilityUtilization Of Your Available Resources

(i.e. Health Information/Record Manual)Health Information Record

Consultant’s Assistance/Training And Utilization

A WELL MANAGED RECORDS DEPT.

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I accept my responsibilities as outlined in my job description and fully realize the impact my duties may have on the licensing status of the facility and on the documentation of quality of care.

I am aware that the Health Insurance Portability and Accountability Act (HIPAA) will protect privacy and security of health information

MY RESPONSIBILITIES –HIM/RECORD MANUAL

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The clinical record is a legal document o Describes the health care services provided to

the resident. o Includes observations, measurements, history

and prognosis and provides evidence of the quality of resident care.

CLINICAL RECORD - A LEGAL DOCUMENT

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The facility has formalized systems in place for the maintenance of records, with records systematically organized and readily accessible.o That means we have systems we say

we will do and that is what we must carry out

o Request Support when you need it and obtain guidance from your consultant

RECORD SYSTEM IS OUTLINED IN THE MANUAL – TO GUIDE US!!

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Do you know what is in it?HAS YOUR CONSULTANT, DIRECTOR OF

NURSING AND ADMINISTRATOR REVIEWED WITH OTHER POLICIES AND PROCEDURES.

REFOCUS II – will be ManualREFOCUS III – will be Quality Assurance

HIM/RECORD MANUAL

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Record Responsibilities (HIM #1015)oThe Administrator shall be responsible for

establishing and maintaining a clinical records system.

oThe Administrator assigns general supervisory responsibility for the record service to a Health Information Designee who is a full-time employee to the facility. The Health Information Designee receives periodic consultation from a qualified clinical record practitioner.

HIM/RECORD MANUAL #1015

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Record Responsibilities (HIM #1015)oThe Administrator delegates the responsibility of

the maintenance of the facility’s record system to the:

Attending physician; Nursing staff; Ancillary personnel; Health Information Designee; Clinical Record Practitioner/

Consultant.

HIM/RECORD MANUAL #1015 -2

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General Record Policies (HIM #2010)oClinical records, paper or electronic, shall be kept

for each resident admitted for care. Content shall be in compliance with licensing and certifying governmental agency requirements and professional standards.

oAll clinical information regarding a resident’s stay shall be centralized in the clinical record.


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General Record Policies (HIM #2010)oThe clinical record provides for:

Planning, continuity of care, and health teaching; Communicating effectively; Evaluating care, health teaching effectiveness; Protecting the legal interests of the:

• Resident;• Facility;• Staff;• Physician.

Conducting research and compiling statistics; Documenting the utilization of resources; Documenting care to meet licensing (state)

certification, federal and accreditation standards (Joint Commission on Accreditation), for reimbursement and to meet third party payer requirements.


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General Record Policies (HIM #2010)oRecords shall be maintained in a

permanent form, computerized, typewritten or legibly written in ink that is capable of being photocopied.

oRecords shall be reviewed periodically for currency and completion, while the resident is in the facility, and shall be reviewed and completed for filing and storage within 30 days after discharge.


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General Record Policies (HIM #2010)oRecords shall be retained for a period of 7 years

from the date of the last discharge, after which time they may be destroyed. Records of minors shall be retained until they have reached majority (18 years) and 3 additional years thereafter, but no less than 7 years after date of last discharge.


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General Record Policies (HIM #2010)o Retention of records for 7 years for the purposes

of the False Claim Act requirements – records according to United States Code 3731.1 False Claim Procedure Title 31, Money and Finance Management, Subtitle II. Financial Management, Chapter 37-Claims. False Claims Procedure. A civil Action under Section 3730 may not be brought more than 6 years after the date on which the violation of Section 3729 is committed or more than 3 years after the date when facts material to the right of action are known or reasonable should have bee known by the official of the US charged with the responsibility to act in the circumstances, but in no event more than 10 years after the date on which the violation is committed, whichever occurs first.


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General Record Policies (HIM #2010)o It seems that you would know the violation within

6 years and would identify those records not to destroy. Although this refers to billing records; clinical records may be needed to support a claim. Retain records for 10 years if the billing office has any claims that have been disputed within a 6 year period and still outstanding.


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General Record Policies (HIM #2010)oMedical Record Retention and Media

Formats for Medical Records – CMS requires Medicare managed care program providers to retain records for 10 years. This requirement is available at 42 CFR 422.504 [d][2][iii] (http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr;sid=ab240bf0e5f6388a75cbe07cc5cf1d21;rgn=div5;view=text;node=42%3A3.0.1.1.9;idno=42;cc=ecfr) on the Internet.

oUSE A COLORED FOLDER OR A STICKER


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Records shall be filed in an accessible manner in the facility or in record storage. Storage of records shall provide for prompt retrieval when needed for continuity of care. Records can be stored off the facility premises only with the prior approval of the Department. Electronic storage of records shall be protected as specified in

RECORDS ACCESSIBLE

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Purpose/General Documentation Guidelines (HIM #2020)o Personnel who document in the medical record

should be credentialed and/or have the authority and right to document as defined by facility policy.

o Individuals must be trained and competent in the fundamental documentation practices of the facility and legal documentation standards.


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Purpose/General Documentation Guidelines (HIM #2020)Every entry shall be recorded promptly as the

events or observations occur.All entries shall be complete, concise, descriptive

and accurate.Any person) making observations or rendering

direct services to the resident shall document in the record.


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Purpose/General Documentation Guidelines (HIM #2020)All entries must be written in chronological

sequence.All like forms filed chronologically/reverse

chronologically.Documentation is required where regulations are

not specific, based on a frequency defined by the facility’s policy, resident’s condition, changes in the resident’s condition, standards of the community and on clinical judgment.


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Purpose/General Documentation Guidelines (HIM #2020)Record pertinent observations, psychosocial and

physical manifestations, incidents, unusual occurrences and abnormal behavior.

Avoid flippant or funny remarks and do not use the record to settle grudges.

Symbols and abbreviations may be used only when approved by the facility. Each symbol and abbreviation should have only one meaning.


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Purpose/General Documentation Guidelines (HIM #2020)Do not mention in the record that an Incident

Report or Notification Form was completed and/or submitted. Do not file incident reports in the clinical file.

All entries shall be permanent, either typewritten or legibly written in permanent ink and capable of being photocopied. Blue or black ink is recommended. If green or red ink is used, the input must be clearly legible when photocopied.


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Purpose/General Documentation Guidelines (HIM #2020)Highlighter may be used, if it will not cause the

input to be illegible when it is photocopied.All entries shall include date – month, day, year

and time as appropriate, and shall be signed. The professional designation or status of the person writing in the record must be clearly shown. Example: MD, RN, LVN, LPN, NA.


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A standardized order of filing shall be followed for all active and discharged records.oOrder of filing in the front of the record.oAssure if there are electronic documents, i.e. ADL

= indicates in the Care Trackero (We will review Admission and Discharge. Audits –

generic some may want to match the order of filing; if so the Consultant will assist you).

ORDER OF FILING

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If the late entry is used to document an omission, validate the source of additional information as much as possible (where did you get the information to write late entry). For example, use of supporting documentation on other facility worksheets or forms.

When using late entries, document as soon as possible. (There is no time limit for writing a late entry, however, the more time that passes the less reliable the entry becomes.)

Do NOT document before an event occurs.

LATE ENTRIES

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LET’S talk about systems!!Calendar – organization/management is

having systems to follow = your home tasks = make a list to get things done.

SCHEDULE – Lets review that ScheduleH.O. #1 – Updated Schedule for 7 days a week

??? And answers????

HEALTH INFORMATION DEPARTMENT EVALUATION

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CareTracker Compliance ReportMedication & Treatment SheetChange of Condition *(New P.O.)Medicare/HMO ChartingBM Tracker RepT.O.s

DAILY AUDITS

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Chart audit/mthly/qtrly reviews.DiabeticPhysical Restraint (if applicable)Physician’s H&P*Psychoactive drug doc. & consentsHospiceRNA

MONTHLY/QUARTERLY AUDITS

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Weekly Summary (Prog. Notes; Monthly Progress Notes for UT, AZ, WA)

Physician Visit *Certs/recerts*Qualitative Tx. Audit – Pressure ulcer* (may

need to add a Pain Assessment column to the Pressure Ulcer Audit

Weights

WEEKLY AUDITS

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Discharge Chart LogUpdate Adm. & Discharge Reg.Purging and filingMonthly orders

KEEP CURRENT AUDITS

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*Admissions*Discharges

AS NEEDED AUDITS

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QA Monitor – CoordinatorCOC (72/24 hr. documentation)24-hr Admission audit (Consent/AD/T.O.s/Dx, CP)Cert/RecertT.O.sCare PlanMedicare ChartingPsychotropicTreatment/Pressure SoreWeekly WeightsBowel & Bladder

NAHC – QA MONITOR

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ADMISSION AUDITS

Review your admission audits and determine the most common missing items.

Work with your neighborTabulate and reportReview and list – group for focus when you

go home. QA follow up.

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QUALITATIVE TREATMENT

Qualitative Treatment Audit –Are you using?What is frequencyLets review the requirementsFocus for AHIS Cons. And HIM/Record Designee

and training in November and December – (if not currently using) new instructions

HIM Monitor #7050 (Treatment Monitor)

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EVALUATION OF RECORD DEPT.STAFF ARE AWARE OF THEIR DUTIES AND

TASKS – CARRY THEM OUT AS PLANNED.Posting Locator – so everyone in your dept.

and outside can locate all the documents/resources.

Out-guides used – in HIM/Records and at Nursing Station

Discharge Charts w/30 days and organized

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EVALUATION OF RECORD DEPT. -2

In-house Chart Organization – all charts are organized, thinned, filed away promptly, dividers readable for inhouse and dividers in all discharges.

Overflow charts are organizedDischarge charts are organized and

immediately in process of discharge after discharge date.

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AUDIT SKILLS

AUDIT SKILLS – Part of the RECORD Department Management – Director of HIM/Records Department is more than audits; it is planning, deploying and working with others aside from their own tasks; knowledgeable about the entire system and getting additional guidance from your AHIS Consultant.

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AUDIT SKILLS – NEW ADMISSIONSH.O. #2 (New Admission Audit)

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CHANGE OF CONDITION

Last five change of condition.Work with your neighbor – tabulate your

findings.Review as a group to determine areas

needing improvementWhat will go to QA??

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SBAR – CHANGE OF CONDITIONReview the new SBAR

H.O. #3 – SBAR Change of ConditionH.O. #4 – SBAR Change of Condition FormNew Policies and Procedures will be provided

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OTHER AUDIT SKILLS

Weekly SummaryMedicare Daily Charting reviewMedicare Certifications – timely tracking

and follow upMD VisitsAnnual H & PQualitative Tx. Audit

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SOME OTHER KEY ISSUES

Audit binders at the Nursing Station Individual notices to staff Informed Administrator and DON = support

for follow up actionQA process – incorporate the results of

auditsACTION TO RESOLVE = USE YOUR

RESOURCES!!!

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DISCHARGES

Discharge processH.O. #6 (Discharge Chart Monitor Draft 10/15/10)

Storage in the Medication Room if resident is to return to the facility, discharged when HIM/Record Director is not there.

DON reviews all unplanned discharges.Resident Record immediate as possible to

the Record Dept.

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PSYCHOTROPIC / BEHAVIORAL MEDICATIONSH.O. #5 (What Is New In

Psychotropic/Behavior Medications)

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EVALUATION

Let’s review the findings from the HIM/Record Department Staff EvaluationIf a facility is less than a “4” =

Best…then there may be variables…not all bad, may be could have been better NOW, could be a new person/s, sickness, etc. This is only an indicator. We are looking for “4” in all areas.

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EVALUATION -2

Department OrganizationSouthern California Northern CaliforniaOther States (AZ, UT, WA)

Admissions/Discharges/Discharge ProcessingSouthern California Northern CaliforniaOther States (AZ, UT, WA)

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LEADERSHIP & MANAGEMENT

A key attribute for the Health Information Management/Records Department

List some key skills you see as important

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BEST PRACTICES

Let’s share!!Set your goals!!What will be your follow up at home?

Medical RecordsDirector of NursingQS/QA staff

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WORKSHOP EVALUATION

Evaluation and feedback Identify other workshops you would like!

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THANK YOU!

Documents

10/21/2010 SOUTHERN CALIFORNIA (Alamitos Belmont) 10/26/2010 NORTHERN CALIFORNIA (Fairfield Post Acute Rehab) To Be Scheduled OTHER STATES via Webinar